Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure that an alleged incident of abuse involving a resident was reported immediately, as required by regulation and facility policy. On the evening of the incident, two CNAs entered a resident's room, spoke loudly, and one CNA used the resident's bamboo back scratcher to touch the resident's lip and possibly his stomach, startling him. The resident responded by throwing water on the CNA, after which the CNA left and returned with another CNA to scold the resident. The facility's investigation later substantiated the abuse allegation based on the resident's account. Despite the policy requiring immediate reporting of alleged violations to the Administrator and/or designee, the initial allegation was not received by the Administrator until three days after the incident. Additionally, the State Survey Agency was not notified until nearly five hours after the Administrator became aware, and Adult Protective Services was not notified at all. Staff interviews revealed that the incident was initially reported via text to a Unit Manager, but the focus was on the resident's behavior rather than the suspected abuse, and the report was not escalated promptly as required.